ATI RN
ATI Gastrointestinal System Questions
Question 1 of 5
The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750ml of green-brown drainage. Which nursing intervention is most appropriate?
Correct Answer: B
Rationale: In this scenario, the most appropriate nursing intervention is to select option B: Document the findings. This is the correct choice because documenting the drainage amount, color, and characteristics is crucial for the ongoing assessment of the client's post-operative condition. Notifying the physician (option A) may be necessary if there are significant changes in the client's condition or if the drainage is excessive, but it is not the most immediate action to take in this situation. Irrigating the T-tube (option C) or clamping the T-tube (option D) without a physician's order can be harmful and should only be done under specific circumstances and with proper authorization. Educationally, understanding the rationale behind documenting findings post-operatively is essential for nursing students. It emphasizes the importance of accurate and timely documentation in providing continuity of care, ensuring appropriate interventions, and facilitating communication among healthcare team members. It also highlights the significance of following proper protocols and seeking guidance from healthcare providers before implementing any interventions.
Question 2 of 5
The client with peptic ulcer disease is scheduled for a pyloroplasty. The client asks the nurse about the procedure. The nurse plans to respond knowing that a pyloroplasty involves:
Correct Answer: D
Rationale: In this scenario, the correct answer is D) An incision and resuturing of the pylorus to relax the muscle and enlarge the opening from the stomach to the duodenum. A pyloroplasty is a surgical procedure performed to treat conditions like peptic ulcer disease by widening the opening between the stomach and the small intestine to improve gastric emptying. This procedure helps to alleviate symptoms such as gastric outlet obstruction and allows for better passage of food from the stomach to the intestines. Option A) Cutting the vagus nerve is incorrect because a pyloroplasty does not involve this nerve; the vagus nerve plays a role in regulating various functions in the gastrointestinal system. Option B) Removing the distal portion of the stomach is incorrect as this describes a different surgical procedure, such as a partial gastrectomy, which involves removing a portion of the stomach, not the pylorus. Option C) Removal of the ulcer and a large portion of the cells that produce hydrochloric acid is incorrect as it describes a different surgical intervention for peptic ulcer disease, such as a gastrectomy or ulcer removal, not specifically addressing the pylorus. Educationally, understanding the rationale behind surgical procedures like pyloroplasty is crucial for nurses caring for patients undergoing these interventions. It ensures accurate patient education and effective post-operative care to promote optimal outcomes and enhance patient understanding and compliance with treatment plans.
Question 3 of 5
A client with a peptic ulcer is scheduled for a vagotomy. The client asks the nurse about the purpose of this procedure. The nurse tells the client that the procedure:
Correct Answer: D
Rationale: Rationale: The correct answer is D) Reduces the stimulus to acid secretions. A vagotomy is a surgical procedure that involves cutting the vagus nerve to reduce the production of stomach acid. By reducing the stimulus to acid secretions, a vagotomy helps in managing peptic ulcers by decreasing the amount of acid in the stomach, which in turn promotes ulcer healing and prevents further damage to the gastric mucosa. Option A) Decreases food absorption in the stomach is incorrect because a vagotomy does not directly affect food absorption. It primarily targets acid secretion. Option B) Heals the gastric mucosa is incorrect because while a vagotomy can indirectly facilitate healing by reducing acid production, its primary goal is to reduce acid secretion rather than directly heal the mucosa. Option C) Halts stress reactions is incorrect as stress reactions are not directly addressed by a vagotomy. Stress can contribute to peptic ulcer formation but is not the primary focus of this surgical intervention. In an educational context, understanding the rationale behind a vagotomy in the context of peptic ulcer management is crucial for nurses caring for patients with gastrointestinal issues. By grasping the purpose of this procedure, nurses can better educate their patients on the expected outcomes and potential benefits of undergoing a vagotomy as part of their treatment plan.
Question 4 of 5
The nurse would assess the client experiencing an acute episode of cholecystitis for pain that is located in the right:
Correct Answer: B
Rationale: In assessing a client with acute cholecystitis, it is crucial for the nurse to understand the typical presentation of this condition. The correct answer is B) Upper quadrant and radiates to the right scapula and shoulder. This is because cholecystitis is inflammation of the gallbladder, which is located in the right upper quadrant of the abdomen. The pain typically radiates to the right shoulder and scapula due to referred pain patterns. Option A) Upper quadrant and radiates to the left scapula and shoulder is incorrect because cholecystitis pain does not typically radiate to the left side. Option C) Lower quadrant and radiates to the umbilicus is incorrect as cholecystitis pain is not typically located in the lower abdomen or radiating to the umbilicus. Option D) Lower quadrant and radiates to the back is also incorrect as cholecystitis pain is not usually felt in the lower quadrant or radiating to the back. Educationally, understanding the specific pain patterns associated with different conditions is essential for accurate assessment and diagnosis in nursing practice. By knowing the expected location and radiation of pain in cholecystitis, nurses can provide prompt and appropriate care to clients experiencing this condition.
Question 5 of 5
Which of the following tasks should be included in the immediate postoperative management of a client who has undergone gastric resection?
Correct Answer: D
Rationale: In the immediate postoperative management of a client who has undergone gastric resection, monitoring for symptoms of hemorrhage (Option D) is crucial. This is because gastric resection is a major surgery that carries the risk of postoperative bleeding, which can be life-threatening if not promptly identified and managed. Monitoring for signs such as tachycardia, hypotension, pallor, and changes in drainage output is essential to detect hemorrhage early and initiate appropriate interventions. Assessing for bowel sounds (Option B) is important in postoperative care, but it is not the priority immediately after gastric resection. Bowel sounds may be diminished or absent in the immediate postoperative period due to factors like anesthesia and bowel manipulation during surgery. Providing nutritional support (Option C) is essential for long-term recovery but is not an immediate postoperative concern. Monitoring gastric pH (Option A) is not typically a priority in the immediate postoperative period after gastric resection, as it is more relevant in conditions like gastric ulcers or gastritis. Educationally, understanding the prioritization of postoperative interventions based on the client's condition and the type of surgery performed is vital for nursing practice. This rationale highlights the importance of recognizing and addressing potential complications following gastric resection to ensure optimal patient outcomes.